NCLEX-PN

Category - Safety

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A client is placed in restraints after becoming extremely aggressive during group therapy. Which of the following actions by the nurse ensures the client’s safety?

The nurse uses a half-bow when securing the restraints to the side rails
The nurse uses a half-bow when securing the restraint to the bed frame
The circulation in the restrained extremities is checked every 2 hours
The restraints are removed every 8 hours

Explanation

Answer: B - The restraints are secured to the bed frame using half-bows for quick or fast release. They are not secured to the side rails. The circulation should be checked every 30 minutes and the restraints should be removed every 2 hours.

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